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The term cholestasis refers to bile acid retention, whether within the hepatocyte or in the bile ducts of any caliber. Biochemically, it is defined by a level of alkaline phosphatase that is 1.67-times higher than the upper limit of normal. Cholestatic diseases can be associated with an inflammatory process of the liver that destroys hepatocytes (hepatitis), withjaundice (yellowing of the skin and mucus membranes, associated with elevated serum bilirubin levels), or with both, albeit the three concepts should not be considered synonymous. Cholestatic diseases can be classified as intrahepatic or extrahepatic, depending on their etiology. Knowing the cause of the condition is important for choosing the adequate diagnostic studies and appropriate treatment in each case. A complete medical history, together with a thorough physical examination and basic initial studies, such as liver ultrasound and liver function tests, aid the clinician in deciding which path to follow, when managing the patient with cholestasis. In a joint effort, the Asociación Mexicana de Hepatología (AMH), the Asociación Mexicana de Gastroenterología (AMG) and the Asociación Mexicana de Endoscopia Gastrointestinal (AMEG) developed the first Mexican scientific position statement on said theme.
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Colestasis , Ictericia , Conductos Biliares , Colestasis/diagnóstico , Humanos , Ictericia/diagnóstico , Hígado , Pruebas de Función HepáticaRESUMEN
Hepatitis B virus (HBV) infection continues to be a worldwide public health problem. In Mexico, at least three million adults are estimated to have acquired hepatitis B (total hepatitis B core antibody [anti-HBc]-positive), and of those, 300,000 active carriers (hepatitis B surface antigen [HBsAg]-positive) could require treatment. Because HBV is preventable through vaccination, its universal application should be emphasized. HBV infection is a major risk factor for developing hepatocellular carcinoma. Semi-annual liver ultrasound and serum alpha-fetoprotein testing favor early detection of that cancer and should be carried out in all patients with chronic HBV infection, regardless of the presence of advanced fibrosis or cirrhosis. Currently, nucleoside/nucleotide analogues that have a high barrier to resistance are the first-line therapies.
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Hepatitis B Crónica , Neoplasias Hepáticas , Adulto , Antivirales/uso terapéutico , Antígenos de Superficie de la Hepatitis B/uso terapéutico , Virus de la Hepatitis B , Hepatitis B Crónica/diagnóstico , Humanos , Neoplasias Hepáticas/diagnósticoRESUMEN
Hepatitis B virus (HBV) infection continues to be a worldwide public health problem. In Mexico, at least three million adults are estimated to have acquired hepatitis B (total hepatitis B core antibody [anti-HBc]-positive), and of those, 300,000 active carriers (hepatitis B surface antigen [HBsAg]-positive) could require treatment. Because HBV is preventable through vaccination, its universal application should be emphasized. HBV infection is a major risk factor for developing hepatocellular carcinoma. Semi-annual liver ultrasound and serum alpha-fetoprotein testing favor early detection of that cancer and should be carried out in all patients with chronic HBV infection, regardless of the presence of advanced fibrosis or cirrhosis. Currently, nucleoside/nucleotide analogues that have a high barrier to resistance are the first-line therapies.
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INTRODUCTION AND AIMS: Primary liver cancer is a public health problem in Mexico and the world. Liver transplantation (LT) is the ideal treatment for early hepatocellular carcinoma (HCC). Our aim was to evaluate the characteristics of patients with HCC and cholangiocarcinoma (CC) at two centers and identify transplantation candidates. MATERIALS AND METHODS: A retrospective observational study was conducted at the Hepatology Center (HC) and the University Center Against Cancer (UCAC), within the time frame of 2012-2018. HCC or intrahepatic CC was confirmed in 109 patients. Staging classifications, transplant selection models, and a predictive model for post-LT recurrence were applied to the HCC patients. RESULTS: Of the total population, 93% (n=102) presented with cirrhosis, 86% (n=94) had HCC (HC: 58%, UCAC: 42%), and 14% (n=15) had intrahepatic CC (HC: 40%, UCAC: 60%). Of the HC patients with HCC, Okuda I-II, BCLC A-B, and AFP levels <100ng/m predominated, whereas Okuda II-III, BCLC C-D, and AFP levels >1000ng/mL predominated in the UCAC patients. Half of the HC population with HCC met the criteria for LT, in contrast to 23% of the UCAC patients. Fifteen patients were evaluated for LT, and at present, six have undergone transplantation. CONCLUSIONS: The most frequent primary liver tumor was HCC. Patients from the HC presented with earlier-stage disease and a high number of them met the criteria for LT. Only patients from the HC underwent transplantation.
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Neoplasias de los Conductos Biliares , Carcinoma Hepatocelular , Gastroenterología , Neoplasias Hepáticas , Carcinoma Hepatocelular/terapia , Humanos , Neoplasias Hepáticas/terapia , Recurrencia Local de Neoplasia , alfa-FetoproteínasRESUMEN
INTRODUCTION AND AIMS: Primary liver cancer is a public health problem in Mexico and the world. Liver transplantation (LT) is the ideal treatment for early hepatocellular carcinoma (HCC). Our aim was to evaluate the characteristics of patients with HCC and cholangiocarcinoma (CC) at two centers and identify transplantation candidates. MATERIALS AND METHODS: A retrospective observational study was conducted at the Hepatology Center (HC) and the University Center Against Cancer (UCAC), within the time frame of 2012-2018. HCC or intrahepatic CC was confirmed in 109 patients. Staging classifications, transplant selection models, and a predictive model for post-LT recurrence were applied to the HCC patients. RESULTS: Of the total population, 93% (n = 102) presented with cirrhosis, 86% (n = 94) had HCC (HC: 58%, UCAC: 42%), and 14% (n = 15) had intrahepatic CC (HC: 40%, UCAC: 60%). Of the HC patients with HCC, Okuda I-II, BCLC A-B, and AFP levels < 100 ng/m predominated, whereas Okuda II-III, BCLC C-D, and AFP levels > 1,000 ng/mL predominated in the UCAC patients. Half of the HC population with HCC met the criteria for LT, in contrast to 23% of the UCAC patients. Fifteen patients were evaluated for LT, and at present, six have undergone transplantation. CONCLUSIONS: The most frequent primary liver tumor was HCC. Patients from the HC presented with earlier-stage disease and a high number of them met the criteria for LT. Only patients from the HC underwent transplantation.
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INTRODUCTION: The sofosbuvir-velpatasvir (SOF/VEL) combination is a direct-acting antiviral therapy that is authorized and available in Mexico, making the performance of a real-world multicenter study that evaluates the sustained virologic response at 12 weeks post-treatment a relevant undertaking. METHODS: A retrospective review of the case records of 241 patients seen at 20 hospitals in Mexico was conducted to assess hepatitis C treatment with the SOF/VEL combination (n = 231) and the sofosbuvir/velpatasvir/ribavirin (SOF/VEL/RBV) combination (n = 10). The primary efficacy endpoint was the percentage of patients that achieved SVR at 12 weeks after the end of treatment. RESULTS: Overall SVR was 98.8% (95% CI 97.35-100%). Only three patients did not achieve SVR, two of whom had cirrhosis and a history of previous treatment with peg-IFN. Of the subgroups analyzed, all the patients with HIV coinfection, three patients with genotype 3, and the patients treated with the SOF/VEL/RBV combination achieved SVR. The subgroups with the lower success rates were patients that were treatment-experienced (96.8%) and patients with F1 fibrosis (95.5%). The most frequent adverse events were fatigue, headache, and insomnia. No serious adverse events were reported. CONCLUSION: Treatments with SOF/VEL and SOF/VEL/RBV were highly safe and effective, results coinciding with those of other international real-world studies.
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El objetivo del Consenso Mexicano para el Tratamiento de la Hepatitis C fue el de desarrollar un documento como guía en la práctica clínica con aplicabilidad en México. Se tomó en cuenta la opinión de expertos en el tema con especialidad en: gastroenterología, infectología y hepatología. Se realizó una revisión de la bibliografía en MEDLINE, EMBASE y CENTRAL mediante palabras claves referentes al tratamiento de la hepatitis C. Posteriormente se evaluó la calidad de la evidencia mediante el sistema GRADE y se redactaron enunciados, los cuales fueron sometidos a voto mediante un sistema modificado Delphi, y posteriormente se realizó revisión y corrección de los enunciados por un panel de 34 votantes. Finalmente se clasificó el nivel de acuerdo para cada oración. Esta guía busca dar recomendaciones con énfasis en los nuevos antivirales de acción directa y de esta manera facilitar su uso en la práctica clínica. Cada caso debe ser individualizado según sus comorbilidades y el manejo de estos pacientes siempre debe ser multidisciplinario.
The aim of the Mexican Consensus on the Treatment of Hepatitis C was to develop clinical practice guidelines applicable to Mexico. The expert opinion of specialists in the following areas was taken into account: gastroenterology, infectious diseases, and hepatology. A search of the medical literature was carried out on the MEDLINE, EMBASE, and CENTRAL databases through keywords related to hepatitis C treatment. The quality of evidence was subsequently evaluated using the GRADE system and the consensus statements were formulated. The statements were then voted upon, using the modified Delphi system, and reviewed and corrected by a panel of 34 voting participants. Finally, the level of agreement was classified for each statement. The present guidelines provide recommendations with an emphasis on the new direct-acting antivirals, to facilitate their use in clinical practice. Each case must be individualized according to the comorbidities involved and patient management must always be multidisciplinary.
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Humanos , Hepatitis C , Hepatitis C/terapia , Ribavirina/uso terapéutico , Hepatitis C/tratamiento farmacológico , Antimetabolitos/uso terapéuticoRESUMEN
The aim of the Mexican Consensus on the Treatment of HepatitisC was to develop clinical practice guidelines applicable to Mexico. The expert opinion of specialists in the following areas was taken into account: gastroenterology, infectious diseases, and hepatology. A search of the medical literature was carried out on the MEDLINE, EMBASE, and CENTRAL databases through keywords related to hepatitisC treatment. The quality of evidence was subsequently evaluated using the GRADE system and the consensus statements were formulated. The statements were then voted upon, using the modified Delphi system, and reviewed and corrected by a panel of 34 voting participants. Finally, the level of agreement was classified for each statement. The present guidelines provide recommendations with an emphasis on the new direct-acting antivirals, to facilitate their use in clinical practice. Each case must be individualized according to the comorbidities involved and patient management must always be multidisciplinary.
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Hepatitis C/terapia , Antivirales/uso terapéutico , Consenso , Medicina Basada en la Evidencia , Hepatitis C/tratamiento farmacológico , Humanos , MéxicoRESUMEN
INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) is associated with an acute inflammatory response and melatonin has a variety of immunomodulatory and antioxidant effects studied experimentally in pancreatobiliary pathology. AIMS: The aim of our study was to evaluate the effects of peri-procedural administration of melatonin on the inflammatory response and lipid peroxidation associated with ERCP. METHODS: In this proof-of-concept clinical trial, 37 patients with a high probability of choledocholithiasis were randomized to receive peri-procedure (ERCP) melatonin or placebo. We measured the serum concentration of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), vascular endothelial growth factor (VEGF), lipid peroxidation, amylase, and liver function tests 24h before and after the procedure. RESULTS: We found no pre-procedure or post-procedure differences between the melatonin group or the placebo group (P>.05) in the serum concentrations of TNF-alpha (melatonin: 153.8 vs. 149.4ng/m; placebo: 103.5 vs. 107.3ng/ml), IL-6 (melatonin: 131.8 vs. 133.3ng/ml; placebo: 177.8 vs. 197.8ng/ml), or VEGF (melatonin: 157.3 vs. 157.8pg/ml; placebo: 97.3 vs. 97.8pg/ml), or in relation to lipid peroxidation (melatonin: 39.2 vs. 72.3µg/ml; placebo: 66.4 vs. 90.5µg/ml). After ERCP, a significant decrease in the AST, ALT, and total bilirubin levels was found only in the melatonin group (P<.05). The administration of melatonin was safe and tolerable. CONCLUSIONS: Melatonin is safe and tolerable in patients undergoing ERCP, but it does not appear to affect inflammatory cytokine concentrations or lipid peroxidation.
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Antioxidantes/uso terapéutico , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Inflamación/etiología , Inflamación/prevención & control , Melatonina/uso terapéutico , Adulto , Anciano , Antioxidantes/efectos adversos , Coledocolitiasis/complicaciones , Coledocolitiasis/diagnóstico , Citocinas/sangre , Método Doble Ciego , Femenino , Humanos , Peroxidación de Lípido/efectos de los fármacos , Masculino , Melatonina/efectos adversos , Persona de Mediana EdadRESUMEN
INTRODUCTION: This study aims to identify the causes for the incomplete donation process at a tertiary care hospital. MATERIALS AND METHODS: A descriptive, retrospective study was performed; all potential donors reported to the Transplant Service within the period of 2005 to 2014 were included. Descriptive statistics were used across frequencies and proportions for categorical variables, central tendency, and dispersion for continuous variables. RESULTS: The total number of deaths reported at the University Hospital (HU) was 8472, of which 815 (n = 815) were reported to COETRA ("Consejo Estatal de Trasplantes"). Among organ or tissue donors, the main known cause of death was head trauma (HT) in 26% (72). Cardiac arrest (CA) as cause of death provided the largest number of donations (141, 57%); of these, 102 (41%) were male and 39 (16%) were female. In comparison, brain death (BD) provided 104 (43%); of these, 65 (27%) were male, and 39 (16%) were female. The age interval was with a higher donation rate was 45 to 49 y (BD 18, CA 22). Donation request was not performed in 359 patients because of medical contraindication 60% (215), rapid deterioration 18% (64), and incomplete donation process 8% (27). Of 452 organ requests, 207 were not accomplished, because of body integrity 28% (57), family disagreement 20% (42), and no acceptance of BE 13% (26). CONCLUSIONS: Opportunity areas: (1) Ensure the notification of all deaths to Transplant Department for identification of potential donors; (2) Reduce rapid deterioration and raise number of completed donation protocols; (3) Increase the donation rate.
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Atención Terciaria de Salud , Donantes de Tejidos/provisión & distribución , Obtención de Tejidos y Órganos/estadística & datos numéricos , Femenino , Humanos , Masculino , México , Persona de Mediana Edad , Estudios RetrospectivosAsunto(s)
Colestasis/complicaciones , Hepatitis Autoinmune/complicaciones , Ácidos y Sales Biliares/metabolismo , Proliferación Celular , Colestasis/terapia , Hepatitis Autoinmune/terapia , Humanos , Cirrosis Hepática Biliar/complicaciones , Cirrosis Hepática Biliar/patología , Pronóstico , ARN Mensajero/biosíntesis , ARN Mensajero/genéticaRESUMEN
BACKGROUND: Cytokines are important in immune and inflammation response in liver transplantation. Determination of cytokine expression may lead to early detection of risk of rejection and infection in patients with this treatment. OBJECTIVE: To evaluate the expression of interleukin- 1beta (IL-1ß), interleukin-6 (IL-6), interleukin-8 (IL- 8), tumor necrosis factor-alpha (TNF-α), transforming growth factor-beta (TGF-ß) and granulocyte macrophage colony stimulating factor (GMCSF) in peripheral blood mononuclear cells in patients who received an orthotopic liver transplantation (OLT). METHODS: Fourteen patient who underwent OLT due to cirrhosis were analyzed before and after (at 24, 48, 72 hours, 7, 15 and 30 days) transplantation. Peripheral blood cells were tested for IL-1ß, IL-6, IL-8, TNF-α, TGF-ß and GM-CSF using semiquantitative reverse transcriptase-polymerase chain reaction (Roche Kit). RESULTS: No patient present acute rejection, and 11 of them had bacterial infections, 1 to 19 days after OTL. The cytokines IL-6 and TNF-α showed no expression in any phases studied and IL-1ß only in 21% in the first phase post-transplant. Sixty percent of patients who presented bacterial infections express GM-CSF. TGF-b was the most frequently expressed cytokine. CONCLUSIONS: Cytokines expression in the evaluated patients did not follow a defined pattern according to etiology. Increasing the size of the sample is deemed important to establish the implication of the diverse cytokines in liver transplantation.
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Células Sanguíneas/metabolismo , Citocinas/biosíntesis , Citocinas/metabolismo , Cirrosis Hepática/cirugía , Trasplante de Hígado , Infecciones Bacterianas/complicaciones , Células Sanguíneas/química , Humanos , Cirrosis Hepática Alcohólica/cirugía , Reacción en Cadena de la PolimerasaRESUMEN
INTRODUCTION: Several programs of organ and tissues transplantation have been developed for over a decade at the University Hospital. OBJECTIVE: To describe long term complications and survival in the liver transplant program at the University Hospital, UANL. MATERIAL AND METHODS: The long term complications and survival were analyzed in the liver transplant program at the University Hospital Dr. José Eleuterio González in the period between 1991 and 2011. RESULTS: Ninety six liver transplants were performed during this period, four of them received one re-transplant and one patient received 2 retransplants. Most common long term complications were metabolic 62%, bony 31% and infectious 28%. Median survival was 78 months. CONCLUSIONS: Liver transplant program at the University Hospital UANL has grown, being the most active in the state of Nuevo Leon, with 1-, 5- and 10-years survival of 66.1, 53.3 and 46.2%, respectively.
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Trasplante de Hígado/estadística & datos numéricos , Adolescente , Adulto , Anciano , Niño , Preescolar , Estudios de Cohortes , Femenino , Hospitales Universitarios , Humanos , Lactante , Trasplante de Hígado/efectos adversos , Masculino , México , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: Tumor necrosis factor alpha (TNF-α) has been involved in the pathogenesis of chronic hepatitis C virus (HCV) infection. Two polymorphisms at positions -308 and -238 in the TNF-α promoter region influence TNF-α expression and these have been linked to a number of infectious diseases. AIM: To analyze the prevalence of the -308 and -238 TNF-α polymorphisms in a group of Mexican HCV-infected patients and in healthy control subjects not related to the patients. MATERIAL AND METHODS: Both polymorphisms were determined in peripheral blood samples from 48 patients with positive anti-HCV antibodies and discernible HCV-RNA levels. Twenty five patients were women and 23 were men. The control group included 100 healthy subjects. Forty-four were women and 56 were men. The polymorphisms were evaluated by polymerase chain reaction amplification (PCR), followed by the Restriction Fragment Length Polymorphism (RFLP) method. RESULTS: The prevalence of the -308 TNF-α polymorphism was found to be 12% in patients with chronic hepatitis C and 20% in control subjects, (P=0.2616); whereas that of the -238 TNF-α polymorphism was found to be 2% and 12% in patients and control subjects, respectively (P=0.061). The TNF-α genotypes were found to be in Hardy-Weinberg equilibrium. CONCLUSIONS: No association was found between -308 and -238 TNF-α polymorphisms and chronic hepatitis C in the Mexican group studied. Our data suggest that additional studies increasing the sample size and a control group which has been exposed to an equal risk of infection are required to investigate whether these polymorphisms represent genetic susceptibility for chronic HCV infection.
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Hepatitis C Crónica/genética , Polimorfismo Genético , Regiones Promotoras Genéticas/genética , Factor de Necrosis Tumoral alfa/genética , Femenino , Humanos , Masculino , México , Persona de Mediana EdadRESUMEN
BACKGROUND: There are few reports in Mexico on the prevalence of infection by virus D. OBJECTIVE: The aim of the present study was to study the hepatitis D virus infection prevalence in patients entering to the University Hospital. METHODS: Seventy three HBsAg positive patients sera were studied. There were 38 patients with acute hepatitis, 28 patients with chronic liver disease and 7 were asymptomatic HBsAg carriers. Serological markers for hepatitis viruses B, D and C were detected by means of ELISA test (Abbott). RESULTS: Anti-HDV was detected in 3 cases (4%). The first two cases were men with acute hepatitis B. Both had a coinfection by viruses B and D, however IgM anticore could not be demonstrated in the first case, this patient developed hepatic cirrhosis within 13 months, in addition he had a concurrent infection by hepatitis C virus with a positive second generation ELISA antibody. The second case recovered from the acute hepatitis. The third case was a female nurse with acute hepatitis and a coinfection by viruses B and D who recovered from the acute attack. Antibody to hepatitis C was present in 3 out of 22 patients with chronic liver disease (13.6%), one of them having an hepatocellular carcinoma. CONCLUSIONS: Our results coincide with the previously reported low incidence of hepatitis D and represent the first report in Mexico of concurrent infections by viruses B-C and B-D-C.
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Hepatitis D/epidemiología , Adolescente , Adulto , Estudios Transversales , Ensayo de Inmunoadsorción Enzimática , Femenino , Anticuerpos Antihepatitis/análisis , Hepatitis B/complicaciones , Hepatitis B/epidemiología , Anticuerpos contra la Hepatitis B/análisis , Antígenos de Superficie de la Hepatitis B/análisis , Hepatitis C/complicaciones , Hepatitis C/epidemiología , Anticuerpos contra la Hepatitis C/análisis , Hepatitis D/complicaciones , Hepatitis D/diagnóstico , Virus de la Hepatitis Delta/inmunología , Humanos , Masculino , México/epidemiología , Persona de Mediana EdadRESUMEN
The p53 tumor suppressor gene is commonly mutated in human hepatocellular carcinoma (HCC). The most frequent mutation in HCC in populations exposed to a high dietary intake of aflatoxin B1 (AFB1) is an AGGarg-->AGTser missense mutation in codon 249 of the p53 gene. We analyzed HCCs from Monterrey, Mexico, for the codon 249ser hotspot mutation. We also analyzed the serum AFB1-albumin adduct levels of the donors and family members to measure the current AFB1 exposure in this population. Moreover, the presence of hepatitis B and/or C viral infection (HBV or HCV) was analyzed serologically in the patients. Tumor cells were microdissected from tissue sections and exon 7 p53 sequences were amplified by polymerase chain reaction from genomic DNA and sequenced directly. The serological tests for anti-p53 antibodies, HBV or HCV were done by ELISA. Immunohistochemical analysis of p53 protein was done using a polyclonal rabbit antiserum (CM-1). Eight of 21 cases were positive by p53 immunohistochemistry. Of the 16 cases sequenced for exon 7 of p53 three codon 249 AGGarg-->AGTser mutations were found. Serum antibodies recognizing p53 protein were found in one of 18 patients. Positive serology for HBV and/or HCV was found in 12 of 20 cases. The serum AFB1-albumin adduct levels in this population ranged from 0.54 to 4.64 pmol aflatoxin/mg albumin. These results indicate that dietary AFB1 and hepatitis viruses are etiological agents in the molecular pathogenesis of HCC in this geographic region of Mexico.